GPs and specialists: a dialogue of the deaf?

June 27, 2018

Ask almost any specialist about their dealings with GPs, and they’re likely to admit that coordination with primary care could be better. And ask any GP about their dealings with specialists, and you may well be on the receiving end of a gripe or two. Melbourne oncologist and Guardian columnist Dr Ranjana Srivastava has recently written that “shared decision-making that involves a specialist and a GP is rare”. She says that for all the talk of teamwork, there’s a lack of communication that has real downsides for the patient. Increasing numbers of patients with chronic comorbidities end up with fragmented care, Dr Srivastava says, with GPs being kept out of the loop due to delayed discharge summaries, and specialists finding it hard to track down busy GPs.

Who’s to blame? According to two large studies, it’s the specialists – if you’re a GP, that is. And of course it’s the GPs, if you’re a specialist. The first study, from the Netherlands, surveyed around 500 doctors – around half of whom were GPs and the rest specialists – about their mutual communications. The vast majority of GPs (85%) thought they were easily accessible by phone. The specialists did not agree: only 32% thought you could easily get a GP on the phone. The specialists were also sniffy about GP referral letters: just 29% of them thought referral letters were generally adequate. Nearly 90% of specialists thought they correctly addressed the issues in the referral letter. Unsurprisingly, the GPs disagreed: only half of them thought specialists adequately addressed the questions.

And did the specialists report back to the GPs in a timely manner? Yes, said 62% of specialists. No, said 78% of GPs. But when they did finally get that specialist report, the GPs overwhelmingly (92%) considered that they followed the specialist’s recommendations. Not so, said the specialists, fewer than half of whom thought the GPs did what was asked of them.

A US study finds similar disagreement between GPs and specialists. This was a considerably larger study involving nearly 50,000 doctors, who were asked about referral and consultations between primary care and specialist physicians. Around 70% of GPs reported that they always or most of the time sent notification of a patient’s history and reason for a referral to a specialist. But there may have been some fibbers among that cohort, as only 35% of specialists said they always or most of the time received such notification. But the imbalance worked both ways: while over 80% of specialists said they always or most of the time sent consultation results to the referring GP, only 62% of GPs agreed that this was the case. Doctors who did not receive timely communications were more likely to report that their ability to provide high-quality care was threatened.

The authors say their study shows the need for “systematic structures, tools and processes for information creation, transfer, receipt, and recognition by the sending and receiving physicians”.

Miscommunication between doctors is widely recognised as one of the main drivers of medical error. The Australian Medical Association has recently published guidelines to improve communications between GPs and other treating doctors. The AMA says specialist outpatient services need to have transparent systems that inform patients and referring doctors of expected wait times for services, and track the priority of referrals.

According to the new guidelines, discharge planning should include telephone, video or face-to-face case conferencing prior to discharge that includes GPs or referring doctors, and a documented plan of care.

“We are delivering very good outcomes for patients in the Australian health system, but we can and should do better. We are confident that the AMA guide will contribute to improved communication and, in turn, better overall care,” AMA President Dr Tony Bartone says.